09050128 CITY OF CUPERTINO
BUILDING DIVISION PERMIT d1RimeCT INRI
M.
BUILDING ADDRESS: PERMIT NO.
11671 TIMBER SPRING CT JUST WATER HEATER I09050128
OWNER'S NAME: PERMIT ISSUE DATE
iN S A CONTROL NO.
(510) 293-9901
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
(� (_ r�
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z U with Section 7000)of Division 3 of the Business and professions Code.and my license is RE P L C 0 GAL WATER HEATER
�y in full force and effect.
D 13? License Class Lic.#
I— Date Contractor
t- ARCHITECTS DECLARATION
R< I understand my plans shall be used as public records
DWU
L Oin Licensed Professional
y� OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m Mg which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z r prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
=C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1200
y 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 366540E4 . 00
❑I,as owner of the property,or my employers with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
[11.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sea .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codc,you must
❑O forthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
Hrte- I hereby affirm that there is a convection lending agency for the performance of
�i the work for which this permit is issued(Sec.3097.Civ.C.)
W Q Lender's Name
aZ Lender's Address
U 0 1 certify that I have read this application and state that the above information is
L%, " correct.I agree to comply with all city and county ordinances and slate laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Dare T of Roof
MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which
If a roof .s installed without first obtaining an inspection,I agree to remove
.it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
-Asuict7
❑Yes ❑No
I have read the ha=dous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a certificate of Occupancy. Signature of Applicant Date
Owner or authorized agent Date I All roof coverings to be Class" 'or better
City of Cupertino Building Permit Application
E-Mail 0g0t 01 99
Jobsite Address: 11671 Timber Spring Ct. Date: May 19, 2009
Owner's Name:---uma Krishnan
Phone No (408)257-8972
APN#: 3669-54-6�s 5(P CQ 417 o Project Valuation $1,200.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 50 gal water he;iter
Contractc r Information
Company: Just Water Heaters Inc. Phone: (510)293-2012
Contact Name: Dulce Fax: (510)293-2022
Address:3400 Investment Blvd :--mail: permits@justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/10
Worker's Comp#: C45096282 Carrier: ACE Exp. Date: 4/1/09
Credit Card Information
Credit Card #: 5474-6390-0047--8660
Name on Card: ,Just Water Heaters Inc.
Expiration Date: 6/11
Visa MasterCard X
Comments
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
CUPEkTINO _
Building Department
JOB ADDRESS: PER 9 (of#
11671 Timber Spring Ct. I i �
OWNER'S NAME: Uma Krishnan PHONE # 408-257-8972
GENERAL CONTRACTOR: JustWater Heaters FAX # 510-783-6360
'`` _�
I am not using any subcontractors: 05/19/09
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUS]NESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing Just Wate Heaters 591329
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
05/19/09
Owner/Contractor Signature Late
10/28/03